Documente Academic
Documente Profesional
Documente Cultură
Page 1
NHSN Piloting Use of Federal Register Notice for Suggestions Related to
Bloodstream Infection and Outpatient Procedure Component Protocols for 2020
NHSN is providing an opportunity for facilities, groups and individuals to identify issues and areas for potential
improvement for consideration as CDC updates and maintains the Bloodstream Infection (BSI) surveillance and new
Outpatient Procedure Component (OPC) protocols for 2020. Comments may be submitted for consideration via
the Federal Register, beginning Thursday February 14, 2019 through Monday April 15, 2019. This will be the only
format for submitting suggested modifications or comments regarding these two types of surveillance for
2019. Users submitting comments/suggested protocol changes to NHSN@cdc.gov will be referred to the Federal
Register while it is active. The protocols are found at these locations:
BSI: https://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html
OPC: https://www.cdc.gov/nhsn/ambulatory-surgery/index.html
Page 2
Electronically Generated Data Accuracy
Because the importance of the accuracy of the data used to meet NHSN definitions cannot be overstated, NHSN
has a requirement to verify accuracy of electronic capture of denominator data. It requires that any difference
between electronically and manually collected denominator data for a given location be 5% or less (pre-validated
for a minimum of three consecutive months)*. However, have you ever thought about the accuracy of the
healthcare-associated infection (HAI) event data that is reported for your facility? Of course, accuracy of the HAI
event data that is reported to NHSN is equally as important as that of the denominator data.
It is important for NHSN users to verify the accuracy of data that is reported to NHSN regardless of whether that
data is collected and entered manually, or via an electronic method. Correct HAI event data reporting starts with
the correct collection of the “elements” of NHSN HAI criteria such as temperature readings, microbiologic
identification of organisms from body specimens or daily minimum PEEP and FiO2 values used for VAE
determination, just to name a few. Is your electronic system collecting these data points accurately? NHSN
provides guidance for validation as it relates to reporting of events using Clinical Data Architecture (CDA) which can
be found at https://www.cdc.gov/nhsn/cdaportal/datavalidation.html, but it cannot test for the correct collection of
these “elemental” data points, whether reporting via CDA or via manual data entry. Therefore, it is incumbent
upon NHSN users to verify the accuracy of all vendor system generated data or “home grown” electronically
generated data used to meet NHSN infection definitions.
A period of parallel testing and comparison of both manual collection and determination as well as electronic
collection and determination is the best way to identify any discrepancies that are present. This is a great way to
identify incorrect manual application of the NHSN protocols and definitions, or problems with electronic capture of
the data elements used in the electronic determination of HAI. Please consider incorporating this process if you
have not already done so.
*Electronic Capture:
For any location, when denominator data are available from electronic sources for example central line days from electronic charting, these
sources may be used as long as the counts are not substantially different (+/- 5%) from manually-collected, once a day counts, pre-validated
for a minimum of three consecutive months.
Corrections have been made to the 2019 operative procedure code documents listed below. The corrections are
highlighted in green within the document (see screenshot below for example).
Page 3
Corrections to the NHSN Operative Procedure Codes (continued)
Updated Guidance Related to the Use of the NHSN Operative Procedure Codes
1. Where are the most current ICD-10-PCS and CPT operative procedure codes found?
• The current list of operative procedure codes are found on the NHSN website in the “Supporting
Materials” section of the Acute Care Facilities module at http://www.cdc.gov/nhsn/acute-care-
hospital/ssi/index.html and the Ambulatory Surgery Centers module at
http://www.cdc.gov/nhsn/ambulatory-surgery/ssi/index.html.
• Procedure code documents of past years are found on the NHSN Data Validation’s webpage
(https://www.cdc.gov/nhsn/validation/index.html) in the “Resources” section of the respective year.
2. When reporting hysterectomy procedures to NHSN, what determines when a procedure is categorized as a
vaginal hysterectomy verses an abdominal hysterectomy? Are there definitions for each of these
procedures?
A trained medical coder, using current medical coding guidelines and conventions, should assign the correct
procedure code (CPT and ICD-10-PCS) to the hysterectomy procedure.
For the purpose of SSI reporting, the NHSN HYST - abdominal hysterectomy operative procedure category
includes hysterectomy procedures / codes that involve an incision into the abdomen, including trocar insertion.
The hysterectomy procedure approach (5th character of the ICD-10 operative procedure code assigned by a
medical coder) identifies whether an abdominal incision was made and determines if the procedure is
categorized as a NHSN HYST or VHYS.
Updated Guidance Related to the Use of the NHSN Operative Procedure Codes continued on page 5
Page 4
Updated Guidance Related to the Use of the NHSN Operative Procedure Codes
(continued)
3. Why are there CPT codes that include “vaginal hysterectomy” in the procedure description included in the
HYST-abdominal hysterectomy procedure category?
Hysterectomy procedures / codes that involve an incision into the abdomen, including trocar insertion are
categorized as NHSN HYST - abdominal hysterectomy procedures; therefore, a few of the CPT codes that
include “laparoscopy, surgical, with vaginal hysterectomy” in the procedure description are included in the
HYST procedure category. The use of a laparoscopic approach indicates that an incision was made into the
abdomen.
Procedure Procedure
Procedure Code Description Code Status
Category Code
Laparoscopy, surgical, with vaginal hysterectomy,
HYST 58550 for uterus 250 g or less Moved from VHYS
4. Using the ICD-10-PCS codes, is there a quick way to know when to select “Scope = YES”?
ICD-10-PCS codes can be helpful in answering the scope question. The fifth character indicates the approach to
reach the operative procedure site:
If the fifth character of the ICD-10-PCS procedure code is a four (4) or F then the field for scope should be YES.
Page 5
Active Emergency Departments and 24 Hour Observation Areas for LabID Reporting
The LabID team would like to remind all acute care facilities participating in the Patient Safety Component to
please confirm that all of your active emergency departments (ED) and 24-hour observation areas are included on
all of your facility’s monthly reporting plans for months in which FacWideIn MRSA bacteremia and C. difficile LabID
data are reported. We recently sent targeted outreach via email to facilities where this scenario took place. We had
a low response rate from this outreach, so we’re taking this opportunity to remind all facilities about the
importance of this requirement.
When a facility first adds the FacWideIn location to a monthly reporting plan for LabID reporting, NHSN will
automatically populate all active ED and 24-hour observation areas to the plan. However, when new ED or 24-hour
observation areas are mapped to your facility after monthly reporting plans are created, facilities need to manually
add these recently mapped units to their plans starting with the months where patient data from these locations
are first available for LabID reporting.
Particularly for active ED and 24-hour observation areas, the inclusion of these units on your reporting plan for all
months of the quarter(s) in which the unit(s) were active and operational is required to ensure full compliance with
NHSN and CMS reporting requirements, and in order to receive an accurate LabID Event SIR for your facility.
To review your monthly reporting plan records, click “Reporting Plan” > “Find” from the left navigation bar in NHSN
and select the appropriate Month and Year. Ensure completed monthly reporting plans include all active required
units for all 3 months of the reporting quarter.
For more information about how FacWideIn MRSA and CDI LabID data are risk adjusted, please see pages 36-40 of
the NHSN Guide to the SIR: https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf
REMINDER: All requirements for NHSN and CMS reporting of MRSA and CDI LabID are available at:
https://www.cdc.gov/nhsn/cms/index.html.
Page 6
Antimicrobial Use & Resistance Module Updates (continued)
Quick Reference Guides for each of these new AR reports are available on our AUR Module webpage under Analysis
Resources: https://www.cdc.gov/nhsn/acute-care-hospital/aur/index.html.
*CDC has defined 16 AR Option phenotypes of epidemiologic importance. Criteria and definitions for the pre-
defined phenotypes can be found here: https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/aur/ar-phenotype-
definitions-508.pdf.
The AUR Module Team has been busy updating and creating new content for the AUR Module. The team updated all
existing AUR Module Quick Reference Guides and created six new ones for AR Option reports:
The team also updated the AU and AR Frequently Asked Questions and the List of Antimicrobial Agents Eligible for
AUR Module and added a new resource containing details for the 2014 baseline SAAR. Head over to the NHSN AUR
Module webpage to check out all of the updates and new content.
Page 7
Reminder! Data for CMS Quality Reporting Programs due Soon!
The following data must be entered into NHSN by May 15, 2019, for facilities that participate in certain CMS quality
reporting programs.
Acute Care Hospitals that participate in the Hospital Inpatient Quality Reporting (IQR) Program:
2018 Quarter 4 (October 1 – December 31) CLABSI and CAUTI data
• All ICU locations
• All NICU locations (CLABSI only)
• Adult and pediatric medical, surgical, and medical/surgical wards
2018 Quarter 4 (October 1 – December 31) Inpatient COLO and HYST SSI data
2018 Quarter 4 (October 1 – December 31) MRSA Bacteremia and C. difficile LabID Events (all healthcare-onset and
community-onset)
• FacWideIN
• ED and 24-hour observation locations
2018 Quarter 4 & 2019 Quarter 1 (October 1 – March 31) Healthcare Personnel Influenza Vaccination Summary data
Cancer Hospitals that participate in the PPS-Exempt Cancer Hospital Quality Reporting Program:
2018 Quarter 4 (October 1 – December 31) CLABSI and CAUTI data (all bedded inpatient care locations)
2018 Quarter 4 (October 1 – December 31) Inpatient COLO and HYST SSI data
2018 Quarter 4 (October 1 – December 31) MRSA Bacteremia and C. difficile LabID Events (all healthcare-onset and
community-onset)
2018 Quarter 4 & 2019 Quarter 1 (October 1 – March 31) Healthcare Personnel Influenza Vaccination Summary data
Inpatient Rehabilitation Facilities (IRFs) that participate in the Inpatient Rehabilitation Facility Quality Reporting
Program:
2018 Quarter 4 (October 1 – December 31) CAUTI data (all bedded inpatient locations)
2018 Quarter 4 (October 1 – December 31) C. difficile LabID Events (all healthcare-onset and community-onset)
• Freestanding IRFs: Reporting by FacWideIN
• IRF units within acute care or critical access hospitals: Reporting by each CMS IRF unit
2018 Quarter 4 & 2019 Quarter 1 (October 1 – March 31) Healthcare Personnel Influenza Vaccination Summary data
• IRF units within acute care or critical access hospitals must submit a separate summary record specifically for the
IRF unit: http://www.cdc.gov/nhsn/pdfs/training/vaccination/hcp-flu-vaccination-summary-reporting-irf-training-
slides.pdf.
Long-Term Acute Care Facilities (LTACs/LTCHs) that participate in the Long-Term Care Hospital Quality Reporting
Program:
2018 Quarter 4 (October 1 – December 31) CLABSI and CAUTI data (all bedded inpatient locations)
2018 Quarter 4 (October 1 – December 31) C. difficile LabID Events (FacWideIN, all healthcare-onset, and community-
onset)
2018 Quarter 4 & 2019 Quarter 1 (October 1 – March 31) Healthcare Personnel Influenza Vaccination Summary data
Please ensure that at least one individual at your facility can access NHSN via their Secure Access Management Services
(SAMS) account and has been assigned appropriate user rights in NHSN to enter and view your facility’s data. To
guarantee that your data is accurately entered into NHSN, verify that; 1) your monthly reporting plans are complete; 2)
you've entered appropriate summary and event data or checked the appropriate no events boxes; and 3) you've cleared
all alerts from your NHSN facility homepage. For additional guidance on ensuring your data are accurately sent to CMS for
Quality Reporting purposes, please visit our website and navigate to the appropriate section(s) for your facility type:
https://www.cdc.gov/nhsn/cms/index.html
If you have any questions, please contact the NHSN Helpdesk: NHSN@cdc.gov. The NHSN Helpdesk is staffed Mondays
thru Fridays, 7 am ET – 5 pm ET, excluding Federal Holidays
Page 8
OUTPATIENT PROCEDURE COMPONENT
Reminders for OPC
The Outpatient Procedure Component (OPC) is up and running. Here are just a few reminders.
To enroll in NHSN as an Ambulatory Surgery Center (ASC) the third digit of the CMS Certification Number (CCN)
should be “C”. This identifies the facility as an ASC.
The CCN is an alphanumeric 10-digit number; the first two digits represent the state identification
number. The third digit is an alpha character that identifies the type of facility. The remaining 7-
digits are the unique facility identifier.
If the CCN is not known, the facility may use the National Provider Identifier (NPI) Number “Lookup Tool” found at
https://www.qualityreportingcenter.com/asc/data/ccn / to cross-reference their CCN.
If the facility does NOT have a CCN at the time of enrollment, the facility should to contact NHSN at nhsn@cdc.gov
for assignment of an NHSN Enrollment Number.
Patient Safety Component (PSC) outpatient procedure data up to and including Oct 31, 2018, have been copied to
and are viewable in the OPC. Although the PSC outpatient procedure data are copied and are viewable in OPC,
these data may only be edited in PSC.
• If the analysis is done in OPC - calculations will be based on OPC risk models.
• If the analysis is done in PSC - calculations will be based on PSC risk models.
OPC risk models are being updated and will soon be available in the application.
SDOM includes four measures that are similar to the ASC Quality Reporting Program measures ASC 1-4. This module
may be used to monitor adverse outcomes occurring after non-NHSN operative procedures as well as after NHSN
operative procedures.
SDOM includes:
• SDOM-1: Patient Burn - unintended tissue injury caused by scalds, contact, fire, chemicals, electricity, or
radiation
• SDOM-2: Patient Fall - sudden, uncontrolled, unintentional downward displacement of the body
• SDOM-3: “Wrong” Event - procedure performed is inconsistent with documented informed consent
• SDOM-4: All-cause Hospital Transfer/Admission - transfer/admission to hospital directly from the ASC for
any reason
Page 9
LONG-TERM CARE FACILITY COMPONENT
LTCF Updates
However, due to feedback from several facilities on the feasibility and burden of trying to separate the inpatient
and outpatient counts, CMS and CDC provided guidance on February 7, 2019, to clarify that the HCP Influenza
Vaccination Summary Measure does not separate out HCP who only work in the inpatient or outpatient areas, or
work in both. Therefore, facilities are allowed to collect and submit a single vaccination count to include all HCP that
meet the criteria, regardless of whether HCP work in inpatient or outpatient areas. The combined count should be
entered into a single influenza vaccination summary data entry screen in NHSN. This includes all units/departments,
inpatient and outpatient, that share the exact same CMS Certification Number (CCN) as the hospital and are
affiliated with the acute care facility.
In other words, beginning with the 2018-2019 influenza season, users should follow the guidance below when
making determinations about which areas of the acute care facility to include when reporting HCP influenza
vaccination summary data to NHSN as part of the Hospital Inpatient Quality Reporting Program:
• Include all inpatient units/departments of the acute care facility sharing the exact same CCN (100%
identical) as the acute care facility, regardless of distance from the facility.
Healthcare Personnel Influenza Vaccination Summary Data Reporting for the 2018-2019 Influenza Season continued on page 10
Page 10
Guidance for Acute Care Facilities: Healthcare Personnel Influenza Vaccination Summary
Data Reporting for the 2018-2019 Influenza Season (continued)
• Include all outpatient units/departments of the acute care facility sharing the exact same CCN (100%
identical) as the acute care facility, regardless of distance from the facility.
• Exclude all inpatient and outpatient units/departments of the acute care facility with a different CCN (even if
different by only one letter or number) from the acute care facility.
This guidance supersedes any specific information that CDC had provided regarding reporting for the CMS Hospital
Inpatient Quality Reporting Program, including information presented during the January 2019 webinars that CDC
hosted for acute care facilities.
Training Materials
Training materials incorporating this guidance have been posted at: www.cdc.gov/nhsn/acute-care-hospital/hcp-
vaccination/index.html.
Questions
If you have further questions about this reporting, please contact the following groups:
• NHSN
nhsn@cdc.gov (Please include ‘HPS Flu Summary-Acute Care’ in the subject line of your message)
• CMS support contractor for the Hospital Inpatient Quality Reporting Program
InpatientSupport@viqrc1.hcqis.org or toll-free at (844) 472-4477
BIOVIGILANCE COMPONENT
Hemovigilance Module – Recently Published Articles
Evaluation of the National Healthcare Safety Network Hemovigilance Module for transfusion-related adverse
reactions in the United States
https://onlinelibrary.wiley.com/doi/full/10.1111/trf.15008
Transfusion-Transmitted Infections Reported to the National Healthcare Safety Network Hemovigilance Module
https://www.sciencedirect.com/science/article/pii/S0887796318301044
Page 11
GENERAL NHSN INFORMATION
NHSN Training Updates
The 2019 NHSN Annual Training will take place March 25 – 29, 2019 – we look forward to seeing you in Atlanta, GA
or providing virtual training for those attending via the Live Webstream!
The training will feature presentations on the general changes for NHSN Patient Safety Component surveillance and
provide participants the information and tools necessary to identify, report, and analyze Ventilator-associated
Events (VAE), Pediatric Ventilator-associated Events (PedVAE), Catheter-associated Urinary Tract Infections (CAUTI),
Central Line-associated Blood Stream Infections (CLABSI), Secondary Bloodstream Infection (BSI) and Site-Specific
Infections, Surgical Site Infections (SSI), MRSA Bacteremia and C. difficile LabID events. Additionally, the course will
feature presentations on validation of healthcare-associated infection data and data quality, reporting and analysis
of antibiotic use and resistance data, the Outpatient Procedure Component (OPC), and information on the upcoming
NHSN Neonatal Component.
Training information, agenda, and links to the webstream are available here:
https://www.cdc.gov/nhsn/training/annualtraining.html (please note the site will no longer be accessible after
March 29, 2019).
The archived webstream video of each session and all presentation slides will be posted to the NHSN website in the
coming months, and NHSN will provide a notification when these are available. If you have questions about the
training, please contact us at NHSNTrain@cdc.gov
Continuing Education
Continuing Education (CE) credits will be available later in
the spring for those watching the NHSN Training via
webstream. NHSN will send an announcement with
instructions on how to obtain CE credits once online training
and CE credits are available. CEs that will be available include
CME, CNE, CPH, and CEU. Please contact
NHSNTrain@cdc.gov with any questions regarding
continuing education for NHSN training activities.
Page 12
CDA Corner
Page 13
NHSN Help Desk Activity Update
Quarter 1, 2019
(Averages)
1,318 Email Inquiries per Week
21 Facilities Enrolled per Week
The National Healthcare Safety Network (NHSN) is a voluntary, secure, Internet-based surveillance system that integrates patient and
healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at CDC.
During 2008, enrollment in NHSN was opened to all types of healthcare facilities in the United States, including acute care hospitals,
long-term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers,
and long term care facilities.
Page 14